"Race and Healing a Nation: Lessons from Health Care's Civil Rights Struggle"May/June 1999 issue of Poverty & Race
The story of the Civil Rights Movement and its impact on voting rights, school integration and use of public facilities has been told often and frequently well. In Healthcare Divided: Race and Healing a Nation (University of Michigan Press, 1999), I tell the story of the far less known but no less dramatic struggle in health care. Five important, largely overlooked lessons inhere in this story:
1. Advocacy by independent health practitioners was one of the keys to the emergence of the Civil Rights Movement: a major threat embedded in the current transition of the health care system is elimination of their ability to play such a role.
In racially segregated communities, few could afford to push against the system. Only black physicians, dentists and ministers were largely insulated from such retaliation. Since they relied on the black community for their livelihood, it was harder for the white establishment to control them. The physicians and dentists were solo, fee-for-service practitioners relying for their income mostly on their patients’ out-of-pocket payments. Payments from health insurance plans contributed little to their income. Their exclusion from staff privileges at the white-dominated hospitals made retaliation more difficult. The backbone of the early pre-1960s Civil Rights Movement in the South was drawn from their ranks. The alliance these leaders fashioned with northern physician groups such as the Medical Committee for Human Rights set in motion the approach that would later be adopted by the Department of Health, Education and Welfare (predecessor to the current Department of Health and Human Services) in enforcing Title VI of the Civil Rights Act for hospitals participating in the Medicare program.
Medical practice is now organized much differently. Most physicians, at least in urban areas, have been absorbed into integrated delivery systems and rely increasingly for their livelihood on payments from large health plans. State medical societies now fight for legislation to prohibit “gag rules” in physician contracts with HMOs. Those rules prohibit physicians from criticizing or even explaining to their patients the incentive systems imposed on physicians by such plans. Such legislation does little, however, to stem the broader chilling effect of these more organized systems on dissent. These systems may choose not to contract with “uncooperative” practitioners, just as white-controlled local communities disciplined dissenters during segregation. What if these integrated delivery systems and managed care financing of services had existed before the Civil Rights era? Would these activist practitioners have been able to act as civil rights advocates in their communities? One could make a convincing case that there would have been no civil rights era and that most of the Jim Crow barriers would have remained unchallenged. It is equally important today to protect the role of health practitioners as independent advocates for their patients and community.
2. The purchasers of health care define the self-interests of providers and, in the process, narrow or widen the system’s racial divisions.
Health services organizations are by and large rational, and racial considerations don’t take precedence over self-interest. In the late 1940’s, the people of Greensboro, North Carolina, whose children were dying from a polio epidemic, worked together to erect, in just 90 days, an integrated hospital in a rigidly segregated community to care for those children. In just a few months, more than 1,000 acute care hospitals, ignoring the trepidation of board members, physicians and patients, broke down the walls that had racially divided their staffs and patients since their founding, to become Medicare providers on July 1, 1966, the date the program began to pay for services. When survival was contingent on elimination of the visible signs of segregation, such practices were quickly and efficiently eliminated.
Unfortunately, however, the self-interest of institutions at present too often works to reinforce that deeply ingrained history. Concerned with losing the private paying white patients who are key to their profitability, nursing homes find ways to shape admission practices and room assignments along racial lines. Hospitals track the suburban flight of their medical staffs and the declining profitability of the payer mix in their service area and choose to relocate or expand operations in the suburbs. Managed care plans run their own numbers, cherry-pick practices in predominantly white, low per capita health insurance cost neighborhoods, and red-line high per capita insurance cost, often predominantly black neighborhoods. As a result, health care becomes more racially divided and more unequal. Changes in conditions of participation, methods of payment and reporting requirements can narrow or widen the divide. Civil rights compliance in the absence of a direct and self-conscious connection to the purchase of services is a hollow ritual.
3. The selective enforcement of Title VI of the 1964 Civil Rights Act exerted a profound, unintended and unacknowledged influence on the organization of health services in the United States.
No purchaser exerted a more profound influence on the racial divisions in health care than Medicare. Participation in the program was conditioned on compliance with Title VI of the 1964 Civil Rights Act. Yet enforcement was selective, reflecting the administrative and political realities faced by the Johnson Administration in launching this ambitious new program. Providers responded selectively, accommodating to these requirements but moderating their impact on the communities they served.
Hospitals were the only part of the health system subjected to field audits by federal inspectors and for which a strong working relationship developed between the federal civil right regulators and local civil rights activists. Random room assignment of hospital patients served as the easily documented acid test of Title VI compliance. Nursing homes, however, were subjected to pro-forma paper compliance reviews, and private physician practices were specifically exempted.
An elegant adaptation to these new constraints by health care providers muted their impact. These adaptations included:
• In-patient care in acute hospitals was reduced – restricting such treatment to extremely sick patients – and at the same time private room accommodations in acute care hospitals were massively expanded.
• More than doubling nursing home bed capacity, increasingly substituting a system, virtually unaffected by Title VI compliance requirements, completely separate and segregated from acute hospital care.
• Increasing emphasis on organizing services on an ambulatory basis, including diagnostic, surgical procedures, rehabilitation, drug and alcohol treatment, and mental health.
The result was a health care system structured differently from that of any other country. The United States has the shortest length of stay and the fewest number of general hospital beds per 1,000 population of any developed country. It has an organizationally separate long-term care system that is unique, with most of the world’s private room acute hospital accommodations. Changes in medical technology, the influence of private practice physicians over in-patient settings, and the efforts of a complex array of insurers to control or shift the costs all contributed to this transformation. Yet those who argue that it is more rational and cost-effective to reduce in-patient stays and expand the provision of services on an ambulatory basis have difficulty explaining why in-patient hospital care is so much more costly on a per capita basis in the United States than in any other developed country. The adaptation to the selective Title VI enforcement provides the most parsimonious, if troubling, explanation.
4. A divided health system persists, both exacerbating and distorting racial disparities.
Nursing home care tends to be the most segregated, and ambulatory care remains highly segregated as well. In part, such racially divided care reflects patterns of geographic and residential segregation. Many of the changes in the organization of care, ironically set in motion in part by the accommodation of providers to selective civil rights enforcement, work to the disadvantage of blacks. For example, the shift away from acute hospital care toward more emphasis on out-patient, home and long-term care has a disparate impact on blacks located in neighborhoods where such resources are in shorter supply. The central issue is not so much that care provided to blacks is bad or even that a racially divided health care system is inherently bad. The issue is that, since health care remains substantially divided along racial lines, changes in health care financing and organization should not be evaluated as if the health care system were not so divided.
Perhaps the most perverse consequence of the failure to acknowledge these racial divisions in the organization and financing of health care is the tendency to attribute characteristics of these systems to the people that use them. The more fragmented, less preventive and episodic use of health care by minorities is translated into a lack of personal responsibility rather than a reflection of the differences in the nature of the institutions providing care and their relationships with their patients. At least some of the reported differences in rates of drug addiction, sexually transmitted diseases and possibly even infant mortality reflect differences in the screening and reporting practices of the settings in which care is provided to blacks as opposed to whites. Such screening and reporting is more likely to be a part of the standard operating procedures of urban clinic settings, where blacks disproportionately receive their care. In effect, these differences in procedures amount to an institutionalized form of racial profiling. Such differences contribute not just to exaggerating racial differences in incidence rates, but to a qualitative difference in the relationship between providers and their patients. That relationship is more likely to be one in which there is a higher level of distrust, where the provider is less of a patient advocate and where, as a consequence, there is a lower level of patient compliance.
5. Health care settings can close racial divisions.
However incomplete and discouraging the longer-term outcomes, there was something almost magical about the quiet disappearance of seemingly intractable barriers. The most powerful part of the story were the events that didn’t happen. On a night in June 1965, Grady Hospital’s twin patient towers in Atlanta were integrated. The nurses, speaking to patients with confident reassurance that none of them felt, informed them that their rooms had been reassigned. There was not a single protest. As noted above, the next year, similar events took place in almost 1,000 U.S. hospitals. The racially explicit signs on entrances and waiting areas changed. Room and floor assignment policies changed. Physicians long excluded received hospital privileges. Most of these changes were non-events escaping the notice of local news media. There were no riots of the kind predicted by alarmed state officials on the wards of state psychiatric hospitals in Virginia, Alabama and Mississippi following integration. Southern legislators, concerned about the trauma that would be inflicted by random room assignment, got Title VI regulations changed to permit attending physicians to certify in writing that the health and recovery of the patient was threatened by their racially mixed room assignment and to have them moved. However inadvertent, it was a powerful social statement. It said that racism was not an imbedded part of a structure of American society but a disease that could be cured, or at least managed. This newly defined complicating medical condition was almost never diagnosed. A seemingly instantaneous and miraculous cure resulted. Physicians and health care institutions had been delegated great latitude and trust in the cure and management of that disease. The lack of protest regarding these changes, which made the integration of hospital settings the quietest and smoothest transition of the civil rights decade, is testament to the effectiveness of that delegation. It is a power that cries out for broader application.
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